PART A: Details of the Complainant

PART B: The Scheme

PART C: Issue a Complaint Against Trustee

Do you wish to bring a Complaint against the trustees of the of the scheme?
Yes No

PART D: Issue a Complaint Against Sponsor

Do you wish to bring a Complaint against the sponsor of the of the scheme or Employer?Yes No

PART E: Issue a Complaint Against Manager/Custodian

Do you wish to bring a Complaint against the manager/custodian or administration of the scheme?Yes No

PART F: This Complaint ever Reported before?

To your knowledge has this complaint or a related matter been brought to the authority before?Yes No

PART G: Previous Proceedings

Have there been any Court or Industrial Court proceedings in connection with this dispute?

Yes No

Has this dispute been referred to an arbitration process under the Arbitration Act or other process?

Yes No

Has this dispute been referred to any other regulatory body or Tribunal apart from the Authority?

Yes No

**Attach copies of all documents and pleadings presented and the judgement or decision
made by the court, tribunal or arbitrator.**

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Facts Relating to the Compliant

Please clearly and concisely explain the complaint or dispute, giving dates and what you think
should be done to put matters right. It is mandatory that you enclose copies of all relevant
correspondence or documents in your possession related to this complaint that may assist us in
addressing the complaint. E.g. evidence of your membership to the scheme such as copy of pay slip or member
statement.

You do not have to use this space. If you wish you may complete a separate sheet, typed if possible.
If using handwriting, please write clearly and in black ink (as with the rest of this form). Then attach it below.

PART I: Details of Representatives (If Any)

Do you wish the RBA to correspond with this representative instead of with you?
Yes No

PART J: Signature

***..Please note that copies of this form and any enclosures or papers received from you will be sent for
comment to the people or bodies that you have named as respondents.***

About RBA

Retirement Benefit Authority

Retirement Benefits Authority (RBA) is a regulatory body under the National Treasury, established under Retirement Benefits Act. The Retirement Benefits Act was enacted as part of the on-going reform process in the financial sector in order to bring the retirement benefits industry under a harmonized legislation, to address the many problems that have hitherto faced the industry.